Maximizing the Payment of Health- Related VR Services by Private Insurers and Medicaid: The VR...

Maximizing the Payment of Health-Related VR Services by Private Insurers and Medicaid: The VR Program and the Affordable Care Act

WEBINAR for VR DirectorsMay 14, 2013

SEMINAR SPONSORED BY AND REPORT PREPARED FOR:

The Rehabilitation Research and Training Center

On Vocational Rehabilitation (VR RRTC)

Institute for Community InclusionUniversity of Massachusetts, Boston

SEMINAR SLIDES AND REPORT PREPARED BY:

Robert “Bobby” SilversteinPOWERS PYLES SUTTER &

VERVILLE, [email protected]

mailto:[email protected]

mailto:[email protected]

INTRODUCTION

• FACT: In 2011, $264 million was spent by State VR agencies for diagnosis and treatment of physical and mental impairments. [RSA-2, Financial Report]

• ISSUE: Whether the Affordable Care Act (ACA) can be used to reduce the expenditure of VR funds for health-related VR services.

• PURPOSE OF WEBINAR: Review a recent paper: Funding Health-Related VR Services—The Potential Impact of the Affordable Care Act on the Use of Private Health Insurance and Medicaid to Pay for Health-Related VR Services.

INTRODUCTION

The presentation:

• Describes the VR POLICY FRAMEWORK pertaining to health-related VR services

• Describes the ACA POLICY FRAMEWORK potentially applicable to health-related VR services

• Highlights RECOMMENDATIONS for maximizing the payment of health-related VR services by private insurers and Medicaid under the ACA

OVERARCHING CONCLUSION

The ACA provides a significant opportunity for State VR agencies to reduce the amount of VR funds used to pay for health-related

VR services, thereby increasing the number of individuals with disabilities served by

the program and/or enhancing the quality of services provided to current individuals

served by the program.

VR POLICY FRAMEWORK

Topics include:

• Comparable Services and Benefits• Physical and Mental Restoration• Participation by Clients in the

Cost of Services Based on Financial Need

Comparable Services and Benefits

• Definition

• Determination of availability and exempt services

• Provision of services

• Interagency coordination

• Responsibilities under other laws

VR POLICY FRAMEWORK

VR POLICY FRAMEWORK

Comparable Services and Benefits—DEFINITION [34 CFR 361.5(10)]

• Services and benefits that are –

– Provided or paid for, in whole or in part, by other Federal, State, or local public agencies, by health insurance, or by employee benefits;

– Available to the individual at the time needed to ensure the progress of the individual toward achieving the employment outcome in the individual's individualized plan for employment; and

– Commensurate to the services that the individual would otherwise receive from the designated State vocational rehabilitation agency.

VR POLICY FRAMEWORK

Comparable Services and Benefits -DETERMINATION OF AVAILABILITY AND EXEMPT SERVICES

• Prior to providing most VR services, the VR agency must determine the availability of comparable services and benefits

• A determination that interrupts or delays certain outcomes not required

• Services exempt from comparable services or benefits determinations

Comparable Services and Benefits—PROVISION OF SERVICES [34 CFR 361.53(c)]

• If comparable services and benefits exist and are available, they must be used by VR agencies to meet, in whole or in part, the costs of VR services.

• If comparable services and benefits exist but are not available, the VR agency must provide VR services until comparable services become available.

VR POLICY FRAMEWORK

Comparable Services and Benefits—INTERAGENCY COORDINATION [34 CFR 361.53(d); see also 34 CFR 363.50]

• The Governor, in consultation with the VR agency and other agencies (e.g., Medicaid agency), must ensure that an interagency agreement or other mechanism takes effect.

• The interagency agreement must delineate:– Financial responsibility– Procedures for reimbursing the State VR agency– Dispute resolution procedures– Procedures for identifying coordination and timely delivery

responsibilities

VR POLICY FRAMEWORK

Comparable Services and Benefits—RESPONSIBILITIES UNDER OTHER LAWS [34 CFR 361.53(e)]

• Obligations of public agencies under ADA and Section 504 or interagency agreements

• VR agency’s responsibilities if other public agencies fail to meet their obligations

• Procedures for claiming reimbursement

VR POLICY FRAMEWORK

Physical and Mental Restoration Services [34 CFR 361.48]

• Physical and mental restoration services (see definition) must be made available by the VR agency, but only to the extent that financial support is not readily available from:

– A source other than the State VR agency (such as through health insurance) or

– A comparable service or benefit (see definition).

VR POLICY FRAMEWORK

Participation by Clients in the Cost of Services Based on Financial Need

• State VR agency may (but is not required to ) consider financial need

• If the State VR agency chooses to consider financial need it must maintain written policies that meet specified conditions.

VR POLICY FRAMEWORK

Participation by Clients in the Cost of Services Based on Financial Need

A financial needs test may NOT be used:• For furnishing personal assistance

services or • As a condition to furnishing VR services to

SSI and SSDI recipients.

VR POLICY FRAMEWORK

EXAMPLES OF STATE POLICIES

• California• Florida• North Carolina • Massachusetts

ACA POLICY FRAMEWORK

• Overview

• Individual Mandate

• Employer Mandate

• Health Care Exchanges, Including Essential Health Benefits

• Changes to Private Health Insurance

• Expansion of Public Programs


Overview

In March 2010, Congress passed and the President signed into law the “Affordable Care Act” (ACA).


Overview

On June 28, 2012, the United States SupremeCourt with the exception of the Medicaid expansion provision upheld all of the provisions of the ACA, including:

– Individual mandate, – Employer mandate, – Health care exchanges, – Essential health benefits package, and – Insurance market reforms.


Overview

With respect to Medicaid: • The Supreme Court held that if a State chooses not to

expand Medicaid eligibility to cover all non-Medicare individuals under age 65 with income up to 133% of the Federal Poverty level, the State may not, as a consequence, lose Federal funding for its existing Medicaid program.

• In other words, the Medicaid expansion is voluntary, not mandatory.

Individual Mandate

– Most individuals will be required to have health insurance beginning in 2014 or pay a financial penalty.

– Individuals who do not have access to affordable employer coverage will be able to purchase coverage through a Health Insurance Exchange.

– For those individuals who cannot afford health insurance, premium and cost-sharing credits will be available.



Employer Mandate

Employers required to provide insurance or pay penalties for employees who receive tax credits for health insurance through the Exchange with exceptions for small employers.

Health Care Exchanges—Establishment

• States are authorized to create State-based Exchanges where individuals and small businesses can purchase insurance. [17 states and DC]

• HHS will establish and operate a Federally-facilitated Exchange in any State that elects not to do so. [26 states]

• In a hybrid model known as State Partnership Exchanges the state may perform plan management and consumer assistance functions and HHS performs the rest of the functions. [7 States]

• Handout identifies states in each category



Health Care Exchanges—Establishment• The Exchanges will provide consumers with

information to enable them to choose among plans.

• Premiums and cost-sharing subsidies will be available to make coverage more affordable.


Health Care Exchanges—Essential Health Benefits

• Effective 2014, qualified health plans in Exchanges will be required to offer essential health benefits that meet a minimum set of standards promulgated by the Secretary of Health and Human Services (HHS).

• All Medicaid “benchmark plans” [see below under “Expansion of Public Programs (Medicaid)] must cover these services by 2014.


Health Care Exchanges—Defining the Essential Health Benefits Package

• States must start with a typical employer plan (base-benchmark plan) and then • Supplement the base plan to comply with the ACA by

providing an essential health benefits (EHB)-benchmark plan.

• HANDOUT includes links to EHB benchmark plan for each state.

Health Care Exchanges—Essential Health BenefitsThe EHB-benchmark plan must include all tengeneral categories and the items and services covered within the categories:

1) Ambulatory patient services2) Emergency services3) Hospitalization 4) Maternity and newborn care 5) Prescription drugs 6) Laboratory services



Health Care Exchanges—Essential Health BenefitsThe EHB-benchmark plan must include all ten general categories and the items and services covered within the categories :

7) Mental health and substance use disorder services, including behavioral health treatment

8) Rehabilitative and habilitative services and devices 9) Preventive and wellness services , including chronic

disease management10) Pediatric services, including oral and vision care


Health Care Exchanges—Defining the Essential Health Benefits Package

In addition, EHB-benchmark plan must be defined so that:• No discrimination• Needs of diverse segments accounted for• Not denied due to present or predicted disability• Appropriate balance among categories


Health Care Exchanges—

•Levels of Coverage •Limits on deductibles


Changes to Private Health Insurance— – Coverage– Preexisting conditions exclusions– Premium ratings– Annual and lifetime limits– Rescissions – Coverage of dependents– Waiting periods– Preventative services and immunizations and cost

sharing– Existing plans


Expansion of Public Programs —Extension of Medicaid Eligibility (As Enacted)

• The ACA, as enacted, was designed to extend and simplify Medicaid eligibility.

• Starting in calendar year 2014, the ACA, as enacted, would have replaced the complex categorical groupings and limitations to provide Medicaid eligibility to cover all non-Medicare individuals under age 65 with income up to 133% of the Federal poverty level ($14,404 for an individual and $29,327 for a family of four in 2009)


Expansion of Public Programs —Extension of Medicaid Eligibility (Supreme Court)

• Supreme Court upholds all of the provisions of the ACA, with the exception of the Medicaid expansion provision.

• Supreme Court holds that if a State chooses not to participate Medicaid expansion, the State may not lose Federal funding for its existing Medicaid program.

• In sum, the Medicaid expansion envisioned by the ACA is now voluntary, not mandatory.


Expansion of Public Programs —Extension of Medicaid Eligibility (Key Policy Changes)

Under the ACA, for those states electing to participate in the Medicaid expansion (up to 133% of the FPL), the following key policy changes apply: • The Federal government will provide between 100% and

90% of funding for the newly eligible between 2014 and 2020 and beyond.


Expansion of Public Programs —Extension of Medicaid Eligibility (Key Policy Changes)

• There is no deadline by which a State must let the Federal government know of its intention regarding Medicaid expansion.

• As of date of webinar, governors in 26 states and the District of Columbia support Medicaid Expansion

• A State which expands eligibility to less than 133% of the FPL will not be eligible to receive the enhanced match.

Expansion of Public Programs —Extension of Medicaid Eligibility (Benchmark Plans)

• It is important to note that the Medicaid eligibility expansion group will not be entitled to the full array of State Medicaid benefits.

• Rather, those individuals will be entitled to “benchmark coverage” or “benchmark equivalent coverage.”

• All Medicaid “benchmark plans” must cover essential health benefits by 2014.



Expansion of Public Programs —Home and Community-Based Services State Plan Amendment

• The ACA includes changes to the HCBS State Plan that enable States to: – Target HCBS to particular groups of people, – Make HCBS accessible to more individuals, and – Ensure the quality of HCBS.


Expansion of Public Programs —Community First Choice Option

• Attendant services and supports must be

provided; and • Additional services and supports must be

made available

INTRODUCTION—

The ACA provides VR agencies with the opportunity to influence State policymakers to reduce use of VR funds to pay for health-related VR services

RECOMMENDATIONS

INTRODUCTION—• Opportunity to Influence regarding:

– State Health Care Exchanges and the scope of the benchmark package of essential health benefits;

– Medicaid expansion and Medicaid benchmark plans; and

– New options under the Medicaid program, including the Community First Choice option.

• Opportunity will be ongoing as state participation in programs evolve.

RECOMMENDATIONS

INTRODUCTION—Major Recommendations

• Modernizing the Federal and State VR Policy Framework

• Determining the Scope of Essential Benefits Package Under the ACA

• Determining the Medicaid Benchmark Plans in Medicaid Expansion States

• Ensuring Funding of Personal Attendants under Medicaid Buy-in and Community First Choice Options

RECOMMENDATIONS

#1: Modernizing the Federal and State VR Policy Framework

• The potential of the ACA to reduce payment by VR agencies for health-related VR services is substantial.

• Examples of health-related VR services include:

– Physical and mental restoration services (e.g., surgery, therapies and mental health and substance abuse disorder services);

– Rehabilitation technology, assistive technology devices and assistive technology services; and

– Personal assistance services.

RECOMMENDATIONS

#1: Modernizing the Federal and State VR Policy FrameworkCurrent legal and policy bases for facilitating payment for health-related VR services by private health insurance and Medicaid include:

• Comparable services and benefits• Limitations on use of VR funds to pay for physical and mental

restoration services• Obligation to develop and maintain written policies and

procedures regarding financial responsibility of individuals.

RECOMMENDATIONS

#1: Modernizing the Federal and State VR Policy Framework

• Recommendation:

– RSA should clarify impact of ACA on payment for health-related VR services.

– Greater leverage for State VR agencies.

RECOMMENDATIONS

#1: Modernizing the Federal and State VR Policy FrameworkThe policy guidance should clarify:

•Use of private insurance and Medicaid prior to use of VR funds•Specific policies and procedures in interagency agreements•Relationship between VR and EHB-benchmark plan

RECOMMENDATIONS

#2: Determining the Scope of Essential Benefits Package Under the ACA

State VR agencies ongoing opportunity to influence decisions by State policymakers regarding coverage of health-related VR services under the EHB-benchmark plan

RECOMMENDATIONS


• Specifically, VR agencies should be involved in decisions relating to determining the scope of the EHB-benchmark plan by: 1) Supplementing the base-benchmark plan to

include all ten benefit categories (and the items and services covered within each category)

RECOMMENDATIONS

RECOMMENDATIONS

Specifically, VR agencies should be involved in decisions relating to determining the scope of the EHB benchmark plan by:

2)Supplementing the base-benchmark plan by ensuring compliance with the non-discrimination provisions of the ACA and ensuring that any plan enhancements provide for an appropriate balance between the various benefit categories.


• Specifically, VR agencies should be involved in decisions relating to: 3) Defining key terms, including

• Rehabilitative services,• Habilitative services, • Rehabilitative and habilitative devices,

RECOMMENDATIONS



• Durable medical equipment, • Orthotics, • Prosthetics,

RECOMMENDATIONS



• Low vision aids, • Augmentative and alternative communication

devices, and • Hearing aids and assistive listening devices.

RECOMMENDATIONS

#2:Determining the Scope of Essential Benefits Package Under the ACA

• Specifically, VR agencies should be involved in decisions relating to: 4) Making plan coverage decisions,

reimbursement rates, incentive programs, and benefit design that are consistent with private market reforms.

5) Continuing to incorporate existing State mandates; and

RECOMMENDATIONS


• Specifically, VR agencies should be involved in decisions relating to:

6) Defining medical necessity

RECOMMENDATIONS

#3: Determining the Medicaid Benchmark Plans in Medicaid Expansion States

Determining

• Benchmark coverage and • Benchmark equivalent coverage.

RECOMMENDATIONS

#4: Ensuring Funding of Personal Attendants under Community First Choice Option

• Ensure payment and comprehensive coverage under the Community First Choice option for personal attendants to accompany and assist individuals with disabilities participating in VR programs as well as in the workplace.

RECOMMENDATIONS

CONCLUSION

The ACA provides a significant opportunity for State VR agencies to reduce the amount of VR funds used to pay for health-related VR services, thereby increasing the number of individuals with disabilities served by the program and/or enhancing the quality of services provided to current individuals served by the program.

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